ABSTRACT
INTRODUCTION: Anti-neoplastic therapy improves the prognosis for advanced cancer, albeit it is not curative. An ethical dilemma that often arises during patients' first appointment with the oncologist is to give them only the prognostic information they can tolerate, even at the cost of compromising preference-based decision-making, versus giving them full information to force prompt prognostic awareness, at the risk of causing psychological harm. METHODS: We recruited 550 participants with advanced cancer. After the appointment, patients and clinicians completed several questionnaires about preferences, expectations, prognostic awareness, hope, psychological symptoms, and other treatment-related aspects. The aim was to characterize the prevalence, explanatory factors, and consequences of inaccurate prognostic awareness and interest in therapy. RESULTS: Inaccurate prognostic awareness affected 74%, conditioned by the administration of vague information without alluding to death (odds ratio [OR] 2.54; 95% CI, 1.47-4.37, adjusted P = .006). A full 68% agreed to low-efficacy therapies. Ethical and psychological factors oriented first-line decision-making, in a trade-off in which some lose quality of life and mood, for others to gain autonomy. Imprecise prognostic awareness was associated with greater interest in low-efficacy treatments (OR 2.27; 95% CI, 1.31-3.84; adjusted P = .017), whereas realistic understanding increased anxiety (OR 1.63; 95% CI, 1.01-2.65; adjusted P = 0.038), depression (OR 1.96; 95% CI, 1.23-3.11; adjusted P = .020), and diminished quality of life (OR 0.47; 95% CI, 0.29-0.75; adjusted P = .011). CONCLUSION: In the age of immunotherapy and targeted therapies, many appear not to understand that antineoplastic therapy is not curative. Within the mix of inputs that comprise inaccurate prognostic awareness, many psychosocial factors are as relevant as the physicians' disclosure of information. Thus, the desire for better decision-making can actually harm the patient.
Subject(s)
Neoplasms , Oncologists , Terminal Care , Humans , Prognosis , Quality of Life/psychology , Terminal Care/psychology , Neoplasms/therapyABSTRACT
Prostate cancer is the second mortality cause among males with cancer. Patients with metastatic castration resistant prostate cancer (mCRPC) essentially die due to tumor progression in a castration resistance situation. Docetaxel based chemotherapy was the first therapeutic strategy that demonstrated a survival increase, in addition to pain decrease, increase in tumor responses and quality of life benefit, and it currently continues being useful after the incorporation of new therapies for the treatment of mCRPC. Cabazitaxel, a taxane with efficacy in docetaxel resistant tumors, was the second drug demonstrating increased survival in this scenario, and it is an additional alternative option effective in selected patients. Patients with aggressive variants and those with DNA repair genes alterations may benefit from platin-based therapies. In the absence of validated biomarkers, we should base our decisions on clinical and patient's preferences criteria. It is important to design a comprehensive therapeutic plan at an early stage including the treatments with demonstrated efficacy on survival. For this, it is essential a comprehensive and multidisciplinary evaluation of the patient at the start of therapy and during tumor evolution. This evaluation must be done with an adequate information process and shared decision together with the patient.
Subject(s)
Antineoplastic Agents/therapeutic use , Docetaxel/therapeutic use , Prostatic Neoplasms, Castration-Resistant/drug therapy , Taxoids/therapeutic use , Humans , MaleABSTRACT
El cáncer de próstata es la segunda causa de mortalidad en varones con cáncer. Los pacientes con cáncer de próstata metastásico fallecen esencialmente por progresión tumoral en situación de resistencia a la castración. La quimioterapia basada en docetaxel fue la primera estrategia terapéutica que demostró un aumento de supervivencia, además de disminución del dolor, aumento de respuestas tumorales y beneficio en calidad de vida, y sigue siendo útil en el momento actual después de la incorporación de las nuevas terapias al tratamiento del cáncer de próstata avanzado. El tratamiento con cabazitaxel, un taxano con eficacia en tumores resistentes a docetaxel, fue el segundo fármaco que demostró aumento de supervivencia en este escenario, y constituye una opción adicional eficaz en pacientes seleccionados. Los pacientes con variantes agresivas y aquellos con alteración en genes reparadores de DNA pueden beneficiarse de tratamientos basados en platino. En ausencia de biomarcadores validados, debemos basar nuestras decisiones en criterios clínicos y de preferencia del paciente. Es importante diseñar de forma precoz un plan terapéutico integral que incluya los tratamientos con eficacia demostrada en supervivencia. Para ello es esencial una valoración integral y multidisciplinar del paciente al inicio del tratamiento y durante la evolución tumoral. Esta valoración debe acompañarse de una adecuada información y consideración del paciente en la toma de decisiones
Prostate cancer is the second mortality cause among males with cancer. Patients with metastatic castration resistant prostate cancer (mCRPC) essentially die due to tumor progression in a castration resistance situation. Docetaxel based chemotherapy was the first therapeutic strategy that demonstrated a survival increase, in addition to pain decrease, increase in tumor responses and quality of life benefit, and it currently continues being useful after the incorporation of new therapies for the treatment of mCRPC. Cabazitaxel, a taxane with efficacy in docetaxel resistant tumors, was the second drug demonstrating increased survival in this scenario, and it is an additional alternative option effective in selected patients. Patients with aggressive variants and those with DNA repair genes alterations may benefit from platin-based therapies. In the absence of validated biomarkers, we should base our decisions on clinical and patient's preferences criteria. It is important to design a comprehensive therapeutic plan at an early stage including the treatments with demonstrated efficacy on survival. For this, it is essential a comprehensive and multidisciplinary evaluation of the patient at the start of therapy and during tumor evolution. This evaluation must be done with an adequate information process and shared decision together with the patient
